This literature review will analyse the current evidence on inadvertent perioperative hypothermia (IPH) in the hospital setting. It is a serious event that can cause serious injury and even death to a person. IPH is often an emergent factor in the post anaesthetic recovery unit (PACU), therefore, it is imperative that staff are trained to identify this condition and commence active management as soon as practicable to reverse the hypothermia. Green et al, 2016 state that although most cases of IPH are preventable, up to 70% of all surgical patients will experience IPH and failure to recognise and treat it can have devastating effects. ( Green et al, 2016) go on to say, that up to 70% of adverse events can be attributed to the lack of team members non-technical skills, such as poor communication poor teamwork, poor leadership and decision making and poor situational awareness. The nursing interventions will include pre warming v intraoperative warming, forced air warming (FAW), circulating water mattresses (CWM), warmed intravenous and irrigation fluids, warm blankets and also amino acid infusion when the peripheral component, hence the drop in core temperature at this time ( Moola & Lockwood 2011). Now talk about what happens when the body becomes hypothermic….to the core versus the peripheries…hypothermia is accompanied by shivering. This literature search was undertaken by searching for all systemic reviews and peer reviewed journals from 2010 to 2016 in the following data bases: EBSCO, CINAHL, EMBASE, CKN, MEDLINE, PubMED and Google Scholar. Also reviewed were the NICE guidelines from 2008 to present. The articles selected involved the immediate postoperative care, therefore studies involving patients transferring straight to ICU were not included in this review.
WHAT IS HYPOTHERMIA Warttig et al, 2014 describes hypothermia as a reduction in a patient’s body heat that occurs in patients in the perioperative setting, resulting from the surgery, surgical environment and/or type of anaesthetic drugs used during the surgery. Perioperative hypothermia is defined as a body core temperature lower than 36°C (Al-Qahtani & Messahel 2011). Abreu, 2011 define a normal body temperature to be around 36.8 C, although this study does say this is not a definite reading. IPH may be caused by multiple factors, such as a cool temperature in the operating room, anaesthetic induced thermoregulation, the patient’s body being exposed in certain operations and also failure to use pre warmed fluids for irrigation or IV solutions (Al-Qahtani & Messahel, 2011) (Hart et al, 2011) (Horosz & Malec-Milewska 2013). Due to the patient fasting usually from midnight the day of surgery and their inactivity while they wait in admissions for their surgery, their metabolism becomes slower and this in turn causes less body heat to produced. There are 2 components in the human body that help to regulate normal body temperature, one being the central component and the other is the peripheral component Singh,A (2013). The central component consists of highly perfused tissue in the brain, head and trunk (Singh, A 2013). The exchange of heat is very rapid in these body parts, with little change to their temperature (Singh,A 2013). The hypothalamus plays a big role regulation the core temperature in the central component (Saper et al 2005). The peripheral component is made up of the skin, hands and lower limbs where the temperature varies due to vascular tone and can be up to 4 degrees colder than the central component (Singh, A 2013). Approx one hour after induction takes place, the central core will redistribute some of its heat to the peripheral component, hence the drop in core temperature at this time ( Moola & Lockwood 2011). Now talk about what happens when the body becomes hypothermic….to the core versus the peripheries… WHAT CAUSES IT Sajid et al, 2009 states that Perioperative hypothermia results in increased intraoperative blood loss yet (blah blah ) study showed that normothermic patients were at a higher risk of postoperative bleeding Forced air warming (FAW) is an effective method of perioperative patient warming and can be started on the admission ward and used throughout surgery and on into the recovery room. This article explores the importance of perioperative warming for surgical patients and the national recommendations for avoiding inadvertent perioperative hypothermia. It also looks at how patient warming is used within the Enhanced Recovery After Surgery (EFIAS) programme. British Journal of Nursing, 2013,Vol 22, No 6 The Enhanced Recovery after Surgery (ERAS) programme suggests that maintaining
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Implementation of a thermal management concept to prevent perioperative hypothermia : Results of a 6-month period in clinical practice].
Menzel M1, Grote R2, Leuchtmann D2, Lautenschläger C3, Röseler C2, Bräuer A
• In total 3228 patients were enrolled into the study. Prewarming was performed in 1329 patients. In 1902 patients active warming was limited to the intraoperative period. The total rate of hypothermia in all patients was 32.6 %, whereas the rate of hypothermia at the end of the operation was 19.3 %. In the group of patients without prewarming the overall rate was 39.1 vs. 25 % at the end of the operation. In the groups of patients with prewarming the total rates of hypothermia were 25.2 and 24.7 % overall and 14.4 and 12.5 % at the end of the operation. In multifactorial regression it could be shown that patients without prewarming had a 1.8-fold increased risk of perioperative hypothermia compared to patients with intraoperative warming only.
• CONCLUSION:
• We conclude that temperature management is a challenge in the clinical situation, and that it is difficult to achieve rates of hypothermia close to zero. The addition of prewarming was very effective in improving the results in our patients.
• KEYWORDS:
• Body core temperature; Forced air warming; Hypopthermic rate; Measurement; Perioperative hypothermia; Prewarming; Temperature
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Anaesthesist. 2016 Jun;65(6):423-9. doi: 10.1007/s00101-016-0158-3. Epub 2016 May 17.
Points
Hypothermia in the perioperative setting
Defenition of hypothermia
Classifications
Causes
Recognising Preventing hypothermia provides multiple benefits beyond saving money and reducing PACU length of stay. The impact of this project can potentially reduce the chance of developing postsurgical complications such as surgical site infections and impaired wound healing. However, a threat to the warming protocol is that other factors, such as patient age or surgery type, can affect the patient’s thermoregulatory response. Therefore, a warming protocol will not always guarantee the patients will be normothermic every time.
Slagle, Joan Abigail, “Implementation of a Warming Protocol to Prevent Inadvertent Perioperative Hypothermia in the Ambulatory Surgical Setting” (2015). Master’s Projects. Paper 161.
• Hypothermia during general anesthesia develops with a characteristic pattern. An initial rapid decrease in core temperature results from a core-to-peripheral redistribution of body heat. This is followed by a slow, linear reduction in core temperature that results simply from heat loss exceeding heat production. Finally, core temperature stabilizes, and subsequently remains virtually unchanged. This plateau phase may be a passive thermal steady state, or result when sufficient hypothermia triggers thermoregulatory vasoconstriction. Results are presented as means ± SDs. Data from Kurz et al. 67 A Kurz, JC Go, DI Sessler, K Kaer, M Larson, AR Bjorksten
• Anesthesiology, 83 (1995), pp. 293–299
What to do
Maintenance
Different methods
Inadvertant hypothermia
14.Moola and Lockwood (2011). This systematic review focused on effective warming methods for prevention and management of IPH.
Results revealed that patients who received preoperative and intraoperative active warming, compared to intraoperatively alone, were less likely to experience IPH after GA induction. Passive warming interventions inconsistently prevented IPH, whether treated preoperatively and intraoperatively, or intraoperatively alone. Examples of active warming included forced warm air and medication administration, while passive warming involved heat reflective blankets, socks, and heated blankets. Moola and Lockwood concluded that the best practice for IPH prevention was the administration of active warming interventions in the preoperative and intraoperative phases of care combined.
Forced air warmers
Connelly, L et al 2016 reviewed 14 articles from CINAHL and pubmed to identify which interventions were most successful in prewarming patients prior to surgery to avoid inadvertent perioperative hypothermia.
Perioperative hypothermia may be caused by multiple factors, such as low ambient temperature in the operating room, inhibition of thermoregulation induced by anaesthesia, exposure of the patient’s body cavities to a cold environment and a lack of pre-warming processes for injection and flushing/lavage solutions (Al-Qahtani & Messahel 2011, Hart et al. 2011, Horosz & Malec-Milewska 2013).
This literature review will discuss the current evidence on inadvertent hypothermia in the postoperative hospital setting.
Postoperative hypothermia is a reduction in a patient’s body heat that occurs in patients in the postoperative setting, resulting from the surgery, surgical environment and/or anaesthetic drugs administered (Warttig et al 2014.)
7. Inadvertent perioperative hypothermia (IPH) is preventable in most cases, yet as many as 70% of surgical patients experience it (Niranjan et al, 2011). It is associated with multiple devastating complications for the patient
20.A core body temperature less than 36”C is defined as hypothermia (NICE 2008, Hart et al 2011)
.The nursing interventions discussed will include forced air warming, pre warming, warm fluids/ warm blankets/irrigation fluid. A literature search was undertaken using the data bases cinhal, embase, Cochrane, Joanna briggs ,,,,,,etc.c The articles chosen in this lit review examines the current trends in optimising patient temperatures in the perioperative environment
It is common for the core body temperature to drop below 35 C withint the first 40m of administration of anaesthesia to a patient. National Institute of health and clinical excellence, Inadvertent perioperative hypotheremia: The management of inadvertent hyoptheremia in adults. NICE clinical guideline 65 2008 (april)
Postoperative patient remains at risk of developing IPH, even after completion of the surgery. During the postoperative phase the body sets about recovering its thermoneutral state.
9. The NICE (2008) guideline recommends that a patient’s temperature should be monitored at 15-minute intervals in the recovery room. Ward transfer should not go ahead until their temperature is above 36°C. The techniques for patient warming and promoting normothermia in this setting are the same as those employed in the operating theatre—forced-air warming is recommended if the patient’s body temperature is below 36°C, until they are discharged back to the ward, or until they feel comfortably warm.
Green etal 2016 state that up to 70% of adverse events can be attributed to the lack of team members non technical skilss, such as poor communication poor teamwork, poor leadership and decidion making and poor situational awareness.
7 Reducing the risks of a patient developing inadvertent perioperative hypothermia is associated with improved outcomes after surgery, especially if used in conjunction with an ERAS
.The nursing interventions discussed will include forced air warming, pre warming, warm fluids/ warm blankets/irrigation fluid. A literature search was undertaken using the data bases cinhal, embase, Cochrane, Joanna briggs ,,,,,,etc.c The articles chosen in this lit review examines the current trends in optimising patient temperatures in the perioperative environment.
Upon the arrival of a patient in pacu(post anaesthetic care unit) a baseline set of vital obs will be atken by the recovery nurse including the pts temparture. This is important because hypothermia can lead to complications such as delayed wound healing, increased bleeding and complication (cochraine2 016). This level 1 evidence as defined by Johanna Briggs institute 20….Expand on what the complications can be
5.A meta analysis by( Chu blah blah ) concluded that forced air warmers were superior to PI (passive insulation)and CWM (circulating water mattress) in preventing hyperthermia. The limitations in this study were that it was non blinded, and therefore the authors concluded that a large scale a randomised control trial was warranted. This also level 1 evidence that supports the use of forced air warmers and this study had no conflict of interest or monetary funding.
Paula Foran pape.. Some surgeons do not like prewarming as they note more intra-operative blood loss
Whilst several sources of level 1 evidence support forced air warmers, there are some concerns from orthopaedic surgeons that these can cause post-operative infections.
(Who agrees or disagrees) just 1 or 2
In this lit review I have discussed
8.The NICE guideline (2008) does not recommend the use of a particular method, only that the practitioner is fully competent using the device. Abreu agrees that there is no gold standard for temperature measurement (Abreu, 2011).
2.Peiwen Zhou et al 2013 studied whether intravenous amino acid (AA) infusion can cure shivering in the postoperative patient. 60 PACU patients with shivering grade 2 or higher and tympanic temp <36 C received either Novamin 18 (AA) infusion, pethidine or tramadol. Novamin showed it can stop postoperative shivering and hypothermia more effectively than pethidine and tramadol . As well as improving pt thermal comfor t, lowered incidence of nausea and vomiting, along with blood glucose increasing and no further shivering. The AA infusion showed a quicker increase in pt temperature indicating improved thermogenesis.
10,More recent NICE medical technologies guidance (NICE, 2011b) has suggested the Inditherm patient-warming mattress as an appropriate alternative to forced-air warming. This device uses low voltage electrical conductive technology to generate a uniform heated surface on which the patient lies (Bernard, 2013). Other key devices for promoting normothermia are intravenous fluid and blood product warmers. Intravenous fluids and blood products over 500 ml should be warmed to 37°C, according to the NICE implementation advice (NICE, 2011c). Additionally, fluids which are to be used intraoperatively for irrigation should be warmed in a thermostat controlled cabinet set at 38–40°C. These interventions all contribute to minimising the risk of IPH on controllable factors.
Table 1. Intraoperative recommendations (The management of inadvertent perioperative hypothermia in adults (NICE, 2008)) Guideline advice Rationale
Patients’ temperature to be measured and documented before induction of anaesthesia
This provides a baseline temperature against which to measure subsequent temperatures
Patients’ temperature to be measured and documented every 30 minutes, between induction of anaesthesia and end of surgery
To closely monitor for decreases in body temperature so interventions can be made promptly
Intravenous fluids and blood products of 500 ml or more are to be warmed to 37˚C using a warming device
To promote normothermia
All patients, both at high and low risk of IPH, should be warmed intraoperatively, from the induction of anaesthesia using a forced-air warming device
There is evidence that shows that forced-air warming is both clinically effective and cost-effective in preventing and treating IPH
Footnote: IPH: inadvertent perioperative hypothermia, NICE: National Institute for Health and Care Excellence
11.Perioperative hypothermia, defined as a body core temperature lower than 36°C (Al-Qahtani & Messahel 2011) remains common, occurring in up to 70% of patients undergoing anaesthetic surgical procedures. In particular, perioperative hypothermia is frequently observed in association with skin, thoracic, abdominal and bone marrow cavity surgeries, because these parts/organs contain a great number of peripheral thermal receptors (Long et al. 2013).
12.Perioperative hypothermia may be caused by multiple factors, such as low ambient temperature in the operating room, inhibition of thermoregulation induced by anaesthesia, exposure of the patient’s body cavities to a cold environment and a lack of pre-warming processes for injection and flushing/lavage solutions (Al-Qahtani & Messahel 2011, Hart et al. 2011, Horosz & Malec-Milewska 2013). Perioperative hypothermia commonly occurs among patients who are older than 70 years; who have a preoperative systolic blood pressure < 140 mmHg, low basic mass index, diabetes, or immune deficiency; and whose surgeries require a long operation time. However, insufficient warming may result in core body temperature falling by 2–6°C (Horosz & Malec-Milewska 2013) and surgical complications (Chiang et al. 2014, Harder et al. 2013, Long et al. 2013), which are caused by reduced thermal comfort in patients (Benson et al. 2012). Therefore, it is essential to use sufficient insulation and warming devices for perioperative patients (Alderson et al. 2014). In clinical practice, passive insulation and active warming systems have been often used to prevent hypothermia during anaesthesia in surgery. The perioperative hypothermia guidelines of the National Institute for Health and Clinical Excellence (2011) indicated that forced-air warming (FAW) can be used to prevent perioperative hypothermia in patients under surgical procedures (Radauceanu et al. 2009). Previous systematic studies on the effectiveness of warming systems (Galv~ao et al. 2009, Poveda et al. 2012, de Brito Poveda et al. 2013, Roberson et al. 2013) stated that circulating-water garments (CWG) are more effective than FAW during surgeries (Galv~ao et al. 2009, Poveda et al. 2012), but others have argued that preoperative application of FAW is more effective than other methods at preventing perioperative hypothermia (de Brito Poveda et al. 2013). However, no recent meta-analysis has been conducted to verify the effectiveness of various warming systems. Indeed, most previous studies did not examine the thermal comfort of patients who used warming devices. Without providing proper warming intervention or equipment during preoperative process, hypothermia will last for several hours and result in more complications and discomfort. Therefore, nurses should help warm the patient’s temperature to at least 36°C and carefully consider the comfort of patients undergoing surgical procedures (Vallet et al. 2013).
All above from Meta-analysis: effectiveness of forced-air warming for prevention of perioperative hypothermia in surgical patients
Hsiao-Chi Nieh & Shu-Fen Su
Accepted for publication 5 April 2016
References
3.Wartig .
4.National Institute of health and clinical excellence, Inadvertent perioperative hypotheremia: The management of inadvertent hyoptheremia in adults. NICE clinical guideline 65 2008 (april)
5. Hsiao-Chi Nieh & Shu-Fen Su 2016.Meta-analysis: efeectiveness of forced air warming for prevention of perioperative hypothermia in surgical patints. Journal of advanced nursing 72(10), 2294-2314. Doi:10.1111/jan.13010.
7 Niranjan N, Bolton T, Berry C (2011) Update in Anaesthesia. Enhanced recovery after surgery – current trends in perioperative care. http://tinyurl.com/ nkkkdk8
8.Abreu M (2011) New concepts in perioperative normothermia: from monitoring to management. http://tinyurl.com/cl7vqx6
9.National Institute for Health and Care Excellence (2008) Inadvertent perioperative hypothermia: the management of inadvertent perioperative hypothermia in adults. http://tinyurl.com/cjy5rep
10.National Institute for Health and Care Excellence (2011b) Indiatherm patient warming mattress for the prevention of inadvertent perioperative hypothermia. http://tinyurl.com/cs38dy6
11.Al-Qahtani A.S. & Messahel F.M. (2011) Benchmarking inadvertent perioperative hypothermia guidelines with the National Institute for Health and Clinical Excellence. Saudi Medical Journal 32(1), 27–31.
11. Long K.C., Tanner E.J., Frey M., Leitao M.M. Jr, Levine D.A., Gardner G.J., Sonoda Y., Abu-Rustum N.R., Barakat R.R. & Chi D.S. (2013) Intraoperative hypothermia during primary surgical cytoreduction for advanced ovarian cancer: Risk factors and associations with post-operative morbidity. Gynecologic Oncology 131(3), 525–530. doi:10.1016/j.ygyno.2013.08.034
14.Moola, S., & Lockwood, C. (2011). The effectiveness of strategies for the management and/or prevention of hypothermia within the adult perioperative environment. International Journal of Evidence Based Healthcare, 9(4), 337-345.
20. Hart S, Bordes B, Hart J et al 2011 Unintended perioperative hypothermia The Ochsner Journal 11 (3) 259-70
Conclusion
IPH is associated with multiple devastating adverse clinical complications, despite the incidence of IPH being largely preventable. Establishing normothermia for each patient is a key factor for improving patient outcomes, avoiding an extensive list of complications and reducing the length of hospital stay. Every member of the theatre team, whether operating department practitioner, health-care assistant, nurse, surgeon or anaesthetist, can champion the implementation of the simple interventions set out by the NICE guidelines.
British Journal of Healthcare Management 2015 Vol 21 No 8
Al-Qahtani A.S. & Messahel F.M. (2011) Benchmarking inadvertent perioperative hypothermia guidelines with the National Institute for Health and Clinical Excellence. Saudi Medical Journal 32(1), 27–31.
Hart S.R., Bordes B., Hart J., Corsino D. & Harmon D. (2011) Unintended perioperative hypothermia. Ochsner Journal 11(3), 259–270.
Horosz B. & Malec-Milewska M. (2013) Inadvertent intraoperative hypothermia. Anaesthesiology Intensive. Therapy 45(1), 38–43. doi:10.5603/ait.2013.0009.